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Where Have All the Doctors Gone? Physician Shortage to Get Worse

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In its latest issue, Texas Hospitals magazine, a
publication of the Texas Hospital Association, featured the
following cover story:

Where Have All the Doctors Gone?
The physician shortage in Texas may get worse before it gets
better

By Steve Jacob

As the decade unfolds, Texas hospitals may be caught
in a physician-shortage vise.

The state faces a wave of newly insured patients
seeking care from a stagnant supply of physicians. That wave
threatens to crash through the doors of hospital emergency
departments when patients cannot get timely
appointments.

The primary care workload is expected to increase by
nearly 30 percent between 2005 and 2025. A number of factors
are feeding this demand, including a growing population; a
flood of baby boomers becoming Medicare beneficiaries and
acquiring medical conditions as they age; and the influx of
newly insured patients under the Patient Protection and
Affordable Care Act.

The supply of primary care physicians is expected to
rise by only 2-7 percent, however. Three out of four physicians
say they already are at or over capacity. The math screams that
there will be a crisis of health care access in the next 15
years. Patients can expect longer waits for appointments,
shorter physician visits, greater use of nonphysicians for
routine care and higher prices.

The physician shortage also will make recruitment of
hospitalists and employed physicians in wholly owned hospital
subsidiaries that much more difficult, and that may escalate
into a bidding war for talent.

The interim charges for the Texas House Committee on
Public Health prior to the 2013 legislative session include
examining the adequacy of the state's primary care workforce
and weighing the impact of an aging population and health care
reform as well as the state and federal funding reductions to
graduate medical education and physician loan repayment
programs. Although the report is not due until this fall, the
findings should be obvious: An already inadequate primary care
workforce will buckle further under the aforementioned
pressures - not to mention the addition of 5 million new Texas
residents this decade. GME and physician loan repayment funding
cuts will mean Texas will force its medical school graduates to
train - and likely settle - elsewhere and lose its investment
in their education.

Reform's Rapid Expansion

An estimated 4.5 million Texans will gain health care
coverage through PPACA. Medicaid expansion accounted for 1.2
million of these patients. The addition of these newly eligible
patients would further exacerbate the current physician
shortage.

Texas has 202 physicians per 100,000 residents,
compared with the national rate of 257, according to the
Centers for Disease Control and Prevention. Texas has fewer
physicians than the national average for 36 out of 40 medical
specialty groups.

The physician-to-population rate has improved slightly
over the past decade because of an influx of out-of-state
physicians, aided in part by the 2003 medical malpractice
reforms. Those physicians have allowed the state to keep up
with population growth. In 2011, about three out of four newly
licensed physicians graduated from medical schools outside
Texas.

That strategy likely will not be as successful in the
future. With health care reform, nearly every state will face
primary care physician shortages, and competition to recruit
and retain physicians will be fierce nationwide.

A study in the New England Journal of Medicine
examined every state's primary care capacity to absorb the
Medicaid expansion in 2014.Texas ranked 47th in its ability to
accommodate the new beneficiaries because of its current high
uninsured rate and low per-capita supply of PCPs. The effect
could be more severe in inner-city urban and rural areas, which
have far fewer providers than suburban areas.

There were 16,830 PCPs in Texas in 2009. The state had
69 PCPs per 100,000 residents, compared with 81 per 100,000
nationally. Nearly half of all Texas counties are classified as
health professional shortage areas, and 29 counties have no
PCPs.

Massachusetts reformed its health care system in 2006,
giving the nation a glimpse of what is to come when access to
health care insurance is expanded without expanding the supply
of PCPs. The average wait for a non-urgent appointment with an
internist rose from 17 days in 2005 to 48 days in 2011. Fewer
than half of family physicians in the state are accepting new
patients, compared with 70 percent four years ago.
Massachusetts has about 108 PCPs for every 100,000 residents,
compared with only about 62 per 100,000 in Texas. This
ultimately suggests an even longer wait locally. Massachusetts
residents used the ED at a rate 40 percent greater than the
rest of the nation.

Tom Banning, chief executive officer and executive
vice president of the Texas Academy of Family Physicians,
describes Texas' outlook as "Massachusetts on
steroids."

"They were hammered with newly insured patients, and
their situation will pale in comparison to what Texas
potentially faces," Banning said. "This is lost on a lot of our
state legislators."

"We know historically that rural hospitals already
have a more difficult time attracting and retaining
physicians," Stultz said. "As the scarcity increases,
physicians will become more particular about what they will and
will not do, like not covering the ED. Physicians will have
more leverage."

The 2011 Legislature did not help matters when it
slashed GME funding. State support of the Family Practice
Residency Program was cut by 72 percent, from more than $20
million in 2010-11 to $5.6 million in 2012-13. The Texas Higher
Education Coordinating Board, which administers program
funding, warned that some training programs might be forced to
close. In 2000, Texas had 247 first-year family medicine
residency positions; by 2011, that number had dropped to
211.

The Primary Care Residency Program was eliminated in
2011. The program trained more than 120 primary care residents.
Texas teaching hospitals also are being targeted in deficit
reduction plans for a 60 percent cut in a Medicare
residency-training subsidy.

The Physician Education Loan Repayment Program,
created by the 2009 Legislature, was cut from $23.2 million in
2010-11 to $5.6 million in 2012-13. The budget cut could affect
health care access for 1.1 million Texans in underserved areas,
according to the Texas Primary Care Office at the Texas
Department of State Health Services.

"Almost every area (of Texas) does not have enough
doctors. There are significant shortages in multiple
specialties across the state," said Darren Whitehurst, vice
president of advocacy at the Texas Medical Association. "If we
could put 500-600 more doctors in the right places, we could
alleviate a lot of the shortages we see today. There are a
number of doctors not locating in shortage areas, but the state
can help alleviate some of the challenges through state payment
policies and issues like loan repayment. The primary payers in
rural and border areas are Medicaid and Medicare, and neither
is paying the cost for providing care."

In addition, more physicians are reducing the number
of patients they see who depend on government insurance for
their health care. According to a recent TMA survey, the number
of Texas physicians accepting new Medicare patients dropped
from 66 percent in 2010 to 58 percent in 2012 and the number
accepting new Medicaid patients dropped from 42 percent to 31
percent - an all-time low.

There is a national shortage of medical residencies
nationally as well. In 2010, there were about 30,500 medical
students competing for some 25,500 residencies. The nation's
medical schools - including those in Texas - are on track to
increase medical school enrollment 30 percent by 2016, a goal
called for by the Association of American Medical Colleges.
However, AAMC President and CEO Darrell Kirch, M.D., noted,
"This won't amount to a single new doctor in practice without
an expansion of residency positions."

Nearly 45 percent of Texas medical school students
leave the state for residency training. According to a TMA
survey, 38 percent of those students would have preferred to do
that training in Texas. Most medical residents set up their
practices within 100 miles of their residency location, so the
$168,000 the state invests in each student's education on
average is lost to another state.

Robert Earley, president/CEO of JPS Health Network in
Fort Worth, pointed out that nearly three out of four of his
hospital's 202 recent GME graduates stayed in the Dallas-Fort
Worth area to practice.

Texas has about one residency position for every
medical school graduate, compared with a ratio of 1.7-to-1 in
California and more than 3-to-1 in New York. The THECB
recommends a ratio of 1.1-to-1. It estimates at least 180
medical school graduates will have to leave the state for their
first year of residency training due to a lack of residency
positions by 2016.

Rallying Stakeholders

Banning said medical schools need incentives to
produce more PCPs and the state needs to fund more PCP
residency slots and restore funding to the Physician Education
Loan Repayment Program. He said he is optimistic that the
Legislature will address the state's primary care
needs.

"The idea of all these new Medicaid recipients
accessing the ED where cost is significantly greater than a
primary care office visit has some legislators spooked about
the budgetary consequences of our lack of primary care access,"
he said.

Whitehurst said he lumps health care with other
pressing state needs.

"Public education, transportation, water - the state
needs to prioritize the programs that need to be funded," he
said. "Otherwise, we will fall further and further behind. This
is not a one-session strategy."

Whitehurst said the Legislature needs to focus on
programs such as GME that actually help complete the training
for becoming a physician in Texas in addition to state payment
policies and loan repayment to help get physicians into
underserved communities.

"There is a lot of talk about new medical schools in
the Valley, Austin and Fort Worth. We need to make sure that if
these programs are created, there are GME opportunities for the
students as well. Otherwise, the state will have spent a lot of
new money educating these students only to lose them to other
states that provide the needed GME programs," he
said.

Earley, a former legislator, said the creation of
brick-and-mortar medical schools resonates more with lawmakers
than GME.

"But we miss out if we don't pair that with GME,"
Earley said. "That is not a gain for Texas taxpayers. The
medical community hasn't effectively gotten that message
across. GME cannot continue to suffer cuts. Demand has gone up,
and we have not met that demand."

Stultz concurs. He notes that THA and TMA are working
together to encourage the Legislature to invest in
GME.

"If we get 100 or more slots created, that's a win.
Anything less is a token," Stultz said. "The problem is that
when you realize it's too late to address the physician
shortage, it's really too late. It could take 10 years to fix
it, and the shortage would get worse during that time. I don't
know when we reach that point of disaster, but we may be
getting near it."

Seton is proud to have four hospitals – the only hospitals in Central Texas - that have earned the Magnet designation, the highest award for nursing excellence given by the American Nurses Association.